Provider Demographics
NPI:1265044184
Name:HERNANDEZ, COLEEN LYNNETTE (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:LYNNETTE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3781 PINE LOG RD
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-6401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:747 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2582
Practice Address - Country:US
Practice Address - Phone:813-290-8560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18223101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health